Navigating V28 and the Changing Regulatory Landscape: 3 Strategies for Health Plans

Navigating V28 and the Changing Regulatory Landscape: 3 Strategies for Health Plans

Health plans are facing a storm of changes with the arrival of the V28 risk adjustment model for Medicare Advantage, along with increased scrutiny from the OIG and CMS. With audits on the rise and regulations constantly shifting, plans need different strategies and approaches to ensure their risk adjustment and quality programs are compliant.

We hosted a panel at RISE National in March with Cambia, Southwestern Health Resources, Independent Health, and Blue Cross of Idaho to discuss these changes, and we identified three strategies that health plans can adopt to stay ahead of the curve: adapting activities to comply with regulatory changes, engaging with providers, and optimizing prospective and retrospective programs.

Adapt to Comply with Regulatory Changes

The V28 risk adjustment model and other regulatory changes are impacting the industry in multiple ways:

  • The OIG is stepping up audits, extrapolating error rates, and providing the methodology that will be used
  • The Part D regulatory changes affect the way CMS is funding and reimbursing plans for the Part D benefit
  • NCQA supports the addition of Adult Immunization Status and Screening for Depression measures in Medicare Advantage Star Ratings

Health plans now must transition their documentation and training as a result of these changes. Additionally, Hierarchical Condition Categories (HCCs) have been recalibrated, which means plans will need time to review the new order. The HCC changes are an attempt to yield $11 billion in savings for the Medicare trust fund in 2024, which will allow plans to focus more on preventative care.

Plans need to adapt their risk adjustment strategy and activities to comply with these regulatory changes. Analytics are the key to identifying the new risk adjustment opportunities based on the V28 model. Additionally, plans should create a compliance strategy that involves identifying possible deletions in claims data and identifying commonly miscoded conditions by using the OIG toolkit.

Engage Providers and Members

Plans also need to leverage data analytics to better understand their providers. Knowing which providers use an EMR, which are paper-based, and whether they take part in a quality incentive program or risk-sharing engagement is key to shaping program design. One size does not fit all, and plans should develop solutions that meet providers where they are.

Additionally, personalized communication for members and providers can significantly improve engagement. Plans can segment members using different criteria – known diagnosis for example, or members who have not yet completed an annual wellness visit. Plans can then develop targeted member and provider messaging accordingly.

Implementing financial incentive programs can also go a long way in engaging both members and providers. Offering a monetary incentive to members for an annual wellness visit or a health assessment can motivate more members to schedule and complete appointments. Plans can also incentivize providers to complete the annual wellness visit to increase engagement.

Optimize Prospective and Retrospective Programs

With increased scrutiny from the OIG and DOJ, health plans using a retrospective program need a compliance process in place. Using analytics to validate net new HCCs and deleting HCCs that do not meet submission standards is one way to ensure compliance with the OIG’s guidelines.

Based on the OIG’s session at RISE National this year, they are targeting audits for unlinked supplemental chart review encounter data submissions. They are also looking at diagnoses submitted from home visits. Adopting a health assessment program for the entire membership would be an ideal strategy. For example, a fall risk assessment done in the home may prevent a fall that would have led to an emergency room visit or rehab stay. Self-reported HEDIS measures can also be collected and shared with HEDIS partners. Plans may also want to engage their clinical teams to ensure members get the right referrals to care management programs or a PCP. For members in rural areas where provider shortages may exist, home visits can be an effective way to bridge this gap so that members are receiving timely care. Plans can also pursue specialist-specific risk arrangements and develop incentive home-based care models to better take care of members.

To educate providers on why they need retrospective charts, transparency is key. Through prospective outreach, they can reduce the administrative burden of other tasks. Transparency enables collaboration with providers to do risk adjustment up front. The more that is done upfront, the better the engagement and delivery of care.


In today’s regulatory environment, it’s crucial for health plans to stay ahead of the game. Strategies that were effective in the past may no longer be reliable, and plans must be prepared to stay compliant and avoid audits. Advantmed’s risk adjustment and quality solutions can help plans not only catch up with the latest changes but also lead the way in navigating these challenges. By partnering with Advantmed, we’ll keep you up to date on the latest trends and strategies to optimize your programs.

To learn more about Advantmed’s risk adjustment solutions, click here.